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Chronic Ear Surgery

K. J. Lee

♦ General Principles

• One has to weigh carefully the pros and cons of a given situation when determining whether surgery is safer than leaving the problem unattended. A case in point is a 75-year-old nonswimmer with a small anterior dry perforation with mild recurrent infection once a year, successfully treated each time with antibiotic eardrops with or without systemic antibiotics. The audiogram shows a 10 dB air–bone gap. Obviously, there are many other scenarios. Although a larger perforation without cholesteatoma can potentially lead to vertigo, facial nerve paralysis, meningitis, and brain abscess, what is the likelihood? One has to balance that probability with the risk of surgical complications prior to embarking on surgery.
  
• A patient with a large perforation or a posterosuperior quadrant perforation without cholesteatoma or not infested with squamous debris can be considered for tympanoplasty without mastoidectomy.
  
• A patient with a perforation with frequently recurrent suppuration with or without cholesteatoma or squamous debris infestation can be considered for one of the following variations of tympanomastoid surgery:
  
  
  
  • Complete simple mastoidectomy with tympanoplasty (reserved for patients with minimal mastoid disease without cholesteatoma)
    
  • Canal wall up facial recess mastoidectomy with tympanoplasty
    
  • Canal wall down mastoidectomy with tympanoplasty
    
  • There are pros and cons to each of these categories. The canal wall up mastoidectomy works well for certain surgeons but has higher failure rates in the hands of inexperienced surgeons. It is generally agreed that a canal wall up mastoidectomy has a slightly higher incidence of recurrent cholesteatoma.
    
  • The canal wall down approach allows the surgeon to more completely eradicate disease. One of the criticisms is that it leaves behind a large cavity, leading to the need for frequent cavity care.
    
  • The author has combined a method of meticulously enlarging the meatus and canal as well as reducing the cavity size in the canal wall down technique. This technique eliminates the requirement for frequent cavity care.
  
  
• When performing myringoplasty or tympanoplasty, one can place the graft laterally, medially, or a combination of the two.
  
• In placing the graft laterally, one has to be sure to deepithelialize the remaining tympanic membrane so as not to bury squamous debris. One has to pack the graft well to avoid anterior sulcus blunting or subsequent lateral displacement of the graft causing poor ossicular contact. To avoid anterior blunting or lateral displacement anteriorly, avoid having the anterior edge of the graft “climb” the anterior canal wall. The anterior edge should be just snug up to the anterior sulcus. Any anterior canal bony bulge should be drilled down. In drilling anteriorly, avoid violating the temporomandibular joint (TMJ), which is situated approximately halfway down and midway between the superior and inferior aspect of the anterior bony canal. Diamond burs should be used when approaching the TMJ. The author uses the medial/underlay grafting technique routinely except for cases of isolated small anterior perforations. Placing the graft medially for a small anterior perforation repair can lead to the graft’s being displaced medially into the eustachian tube orifice in the protympanum.
  
• Eliminating the conductive hearing loss is a function of eliminating middle ear disease, preserving mucosa in the middle ear, and restoring aeration in the middle ear, allowing a phase difference between the oval and round windows.
  
  
  
  • A patient with a type III tympanoplasty without an ossicular replacement prosthesis, who has a well-aerated middle ear, can have an air–bone gap of no more than 10 to 15 dB. Hence, in performing ossicular reconstruction, one needs to pay attention to restoring middle ear aeration.
    
  • A type IV tympanoplasty (in which the graft is on the footplate) with a pocket of air over the round window niche can have an air–bone gap of no more than 30 dB. It is ideal to have a “columella” reconstruction, to convert a type IV into a type III tympanoplasty.
  
  
• The use of Gelfilm® helps to prevent adhesions and, in certain cases, promulgates the regeneration of middle ear mucosa. An atelectatic ear will always have poor hearing.

Special Considerations for Canal Wall Down Mastoidectomy

• Common pitfalls of canal wall down mastoidectomy include the following:
  
  
  
  • Postoperative meatus or canal may be too small.
    
  • Too little skin grafting to help epithelialization
    
  • The mastoid cavity is too big relative to the size of the meatus.
    
  • Packing may cause more granulation tissue, and when removed leads to more scar tissue and “weeping.”
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